Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Legal Non-Compliance inspection at the facility today. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. Areas discussed:

A. Licensee shall operate the facility in substantial compliance with regulations and statures governing the operation of a residential care facility for the elderly. The LPA focused on the physical plant and the infection control protocol. Signs were observed in common areas that promoted guidance around COVID-19, appropriate masking, physical distancing, and the disinfection protocol. The facility continues to monitor the vitals, symptomatic screening, and temperatures of the staff and visitors that come into the community. Hand sanitizer was available throughout the community. Staff were observed wearing appropriate face coverings. The LPA observed residents engaging in group activities, which were led by staff. Activity rooms and common spaces appeared clean and in good repair. Common restrooms were observed, and the LPA observed signs in the restrooms that promoted good hand hygiene. At 9:35 a.m., the hot water measured in the common restroom at 113.1 F. Restrooms were stocked with paper towels and soap. The LPA observed appropriate outdoor furniture in the gated courtyards, with a covered shaded area for residents. The exterior and interior grounds were free of clutter and/or obstructions. The community has a swimming pool, which is locked.

B. Career Smart will conduct quarterly audits and have weekly calls with the Administrator. Staff confirmed that weekly calls are still taking place, every Wednesday. The two-day audit last took place on 6/1/2022 and 6/2/2022. Career Smart will be in the community to complete the audit on September 7 th and 8 th .

C. Licensee will include specific inquiries regarding sexual behaviors and aggressive behaviors during the initial evaluation of new residents Reappraisals will address sexual behaviors and aggressive behaviors when such conduct is evident . The community has not admitted anyone with these specific behaviors within the past two months, but this addendum is included in the assessment for all residents.